RN Exit Comprehensive Predictor - 180 Questions (2019 Version Updated for 2023)

RN Exit Comprehensive Predictor - 180 Questions (2019 Version Updated for 2023) Positioning Clients...Hypophysectomy - ansa. Elevate the HOB to prevent increased ICP Positioning Clients...Thyroidectomy - ansa. Semi-Fowler's to Fowler's to reduce swelling and edema in the neck area. b. Sandbags or pillows may be used to support the patients head and neck. c. Avoid neck extension to decrease tension on the suture line. Positioning Clients...Hemorrhoidectomy - ansa. Assist the client to a lateral position to prevent pain and bleeding. Positioning Clients...GERD - ansa. REVERSE trendelenburg. b. promotes gastric emptying and prevent esophageal reflux. Positioning Clients...DURING a liver biopsy - ansa. Position the patient SUPINE, with the right side of the upper abdomen exposed. b. Client's right arm is raised and extended behind the head and over the left shoulder. c. Liver is located on the right side; this position provides for maximal exposure of the right intercostal spaces. Positioning Clients...AFTER a liver biopsy - ansa. RIGHT lateral position b. Small pillow or folded towel under the puncture site for at least 3 hours to provide pressure to the site and prevent bleeding. Positioning Clients...Paracentesis - ansPositioned in a semi-fowler's position in bed or sitting upright on the side of the bed or in a chair with the feet supported. Positioning Clients...Nasogastric tube insertion - ansa. HIGH Fowler's w/ head tilted forward. b. Closes trachea and opens the esophagus. Positioning Clients...Nasogastric tube irrigations and tube feedings - ansa. Elevate the HOB 30 to 45 degrees to prevent aspiration. b. Maintain head elevation for 1 hour after an intermittent feeding c. HOB should remain elevated for continuous feedings. Positioning Clients...Rectal enema and irrigations - ansa. LEFT Sims' position to allow the solution to flow by gravity in the natural direction of the colon. Positioning Clients...COPD - ansa. Sitting position b. Leaning forward with client's arms over several pillows or the overbed table. Positioning Clients...Laryngectomy - ansa. Semi-Fowler's or Fowler's position to maintain a patent airway. Positioning Clients...Bronchoscopy - ansa. Semi-Fowler's to prevent choking or aspiration Positioning Clients...Postural drainage - ansa. Lung to be drained should be in the uppermost position. b. Trendelenburg Positioning Clients...Thoracentesis - ansa. Sitting on the edge of the bed and leaning over the bedside table with feet supported on a stool b. Lying in bed on the unaffected side with the HOB elevated about 45 degrees. Positioning Clients...Abdominal Aneurysm Resection - ansa. LIMIT HOB elevation to 45 degrees to avoid flexion of the graft. b. Client may be turned from side to side. Positioning Clients...Lower extremity amputation - ansa. First 24 hours after amputation, elvate the foot of the bed. b. Stump is supported with pillows but NOT elevated because of the risk of flexion contractures. CRACKLES upon auscultation Fluid Volume Excess: Neuromuscular Assessment - ansAltered LOC Headache Visual disturbances Skeletal muscle weakness Paresthesias Fluid Volume Excess: Renal Assessment - ansIncreased urine output if kidneys are able to compensate; decreased urine output if kidney damage is the cause Fluid Volume Excess: Integumentary Assessment - ansPitting edema in dependent areas Pale, cool skin Fluid Volume Excess: GI Assessment - ansIncreased motility in the GI tract Diarrhea Increased body weight Liver enlargement Ascites Fluid Volume Excess: Labs - ansDECREASED serum osmo DECREASED hematocrit DECREASED BUN DECREASED serum sodium DECREASED urine specific gravity Interventions for dehydration - ans1. Oral rehydration if possible 2. IV fluids if dehydration is severe 3. Monitor I&O's Hyponatremia Assessment: CV - ans1. Vary w/ changes in vascular volume 2. Normovolemic: Rapid pulse, normal BP 3. Hypovolemic: thready, weak, rapid pulse, hypotension, flat neck veins, normal or low CVP 4. Hypervolemic: rapid, bounding pulse, BP normal or elevated, normal or elevated CVP Hyponatremia Assessment: Respiratory - ansShallow, ineffective respiratory movement is a late manifestation related to skeletal muscle weakness Hyponatremia Assessment: Neuromuscular - ans1. Generalized muscle weakness that is worse in the extremities 2. Diminished DTR's Hyponatremia Assessment: CNS - ans1. Headache 2. Personality changes 3. Confusion 4. Seizures 5. Coma Hyponatremia Assessment: GI - ans1. Increased motility and hyperactive bowel sounds 2. Nausea 3. Abdominal cramping and diarrhea Hyponatremia Assessment: Renal - ansINCREASED Urine Output Hyponatremia Assessment: Integumentary - ansDry mucous membranes Hyponatremia Assessment: Labs - ansSerum sodium less than 135 mEq/L DECREASED urine specific gravity Hypernatremia Assessment: CV - ansHR and BP respond to vascular volume status Hypernatremia Assessment: Respiratory - ansPulmonary edema if hypervolemia is present Hypernatremia Assessment: Neuromuscular - ansEarly: Spontaneous muscle twitches; irregular muscle contractions Late: Skeletal muscle weakness; DTR's diminished or absent Hypernatremia Assessment: CNS - ansAltered cerebral function is the most common manifestation of hypernatremia Normovolemia/hypovolemia: agitation, confusion, seizures Hypervolemia: lethargy, stupor, coma Hypernatremia Assessment: GI - ansExtreme thirst Hypernatremia Assessment: Renal - ansDecreased urine output Hypernatremia Assessment: Integumentary - ansDry and flushed skin Dry and sticky tongue and mucous membranes Presence or absence of edema, depending on fluid volume changes Hypernatremia Assessment: Labs - ansSerum sodium GREATER than 145 mEq/L Increased urinary specific gravity Causes of hypernatremia - ansDECREASED renal excretion a. corticosteroids b. Cushing's syndrome c. Kidney disease d. Hyperaldosteronism e. EXCESS sodium intake f. DECREASED water intake g. INCREASED water loss Causes of hypokalemia... - ansALKALOSIS Excess INSULIN Dilution of serum potassium: 1. Water intoxication 2. IV therapy with K deficient solutions Interventions for hypokalemia - ans1. Place on CARDIAC monitor 2. K supplementation 3. Liquid KCl 4. IV KCl, NEVER IV push, subQ, IM Maximum recommended infusion rate for potassium chloride IV is... - ans5 to 10 mEq/hour NEVER to exceed 20 mEq/hour Potassium infusion can cause phlebitis, frequent IV assessment. Hypokalemia Assessment: CV - ans1. Thready, weak, irregular pulse 2. Weak peripheral pulses 3. Orthostatic hypotension Hypokalemia Assessment: Respiratory - ans1. Shallow ineffective respirations that result from profound weakness 2. Diminished breath sounds Hypokalemia Assessment: Neuromuscular - ans1. Anxiety, lethargy, confusion, coma. 2. Skeletal muscle weakness, leg cramps 3. Loss of tactile discrimination 4. Paresthesias 5. Deep tendon HYPOreflexia Hypokalemia Assessment: GI - ans1. Decreased motility, hypoactive to absent bowel sounds 2. Nausea, vomiting, constipation, abdominal distention 3. Paralytic ileus Hypokalemia Assessment: Labs - ansSerum potassium lower than 3.5 mEq/L EKG Changes 1. ST depression 2. Shallow, flat or inverted T waves 3. Prominent U wave Hyperkalemia Assessment: CV - ansSlow, weak, irregular HR Decreased BP Hyperkalemia Assessment: Respiratory - ansProfound weakness of the skeletal muscles leading to respiratory failure. Hyperkalemia Assessment: Neuromuscular - ansEarly: muscle twitches, cramps, paresthesias (tingling and burning followed by numbness in the hands and feet and around mouth.) Late: Profound weakness, ascending flaccid paralysis in the arms and legs (trunk, head, and respiratory muscles become affected when the serum potassium level reaches a lethal level) Hyperkalemia Assessment: GI - ans1. Increased motility, hyperactive bowel sounds 2. DIARRHEA Hyperkalemia Assessment: LABS - ansSerum potassium level GREATER than 5.0 mEq/L EKG changes: 1. Tall peaked T waves 2. Flat P waves 3. WIDE QRS complexes 4. Prolonged PR intervals. EKG Changes in HYPOCALCEMIA - ans1. Prolonged ST segment 2. Prolonged QT interval EKG Changes in HYPERCALCEMIA - ans1. Shortened ST segment 2. Widened T wave EKG Changes in HYPOKALEMIA - ans1. ST depression 2. Shallow, flat, or inverted T wave 3. Prominent U wave EKG Changes in HYPERKALEMIA - ans1. Tall peaked T waves 2. Flat P waves 3. Widened QRS complexes 4. Prolonged PR interval EKG Changes in HYPOMAGNESEMIA - ans1. Tall T waves 2. Depressed ST segment EKG Changes in HYPERMAGNESEMIA - ans1. Prolonged PR interval 2. Widened QRS complexes SOME causes of hyperkalemia... - ans1. Tissue damage 2. Acidosis 3. Hyperuricemia 4. Hypercatabolism Interventions for HYPERKALEMIA - ans1. Place on CARDIAC MONITOR 2. RESTRICT K 3. Impaired renal function, give Sodium Polystyrene Sulfonate (Kayexalate) 4. Dialysis if K is critically high 5. IV calcium is hyperkalemia is severe to avert myocardial excitability. 6. Hypertonic glucose w/ insulin to move excess potassium into the cells. 7. Avoid salt substitutes Hypocalcemia Assessment: CV - ans1. Decreased HR 2. Hypotension 3. Diminished peripheral pulses Hypocalcemia Assessment: Respiratory - ansNot directly affected; respiratory failure or arrest can result from decreased respiratory movement because of muscle tetany or seizures Hypocalcemia Assessment: Neuromuscular - ans1. Irritable skeletal muscles: twitches, cramps, tetany, seizures 2. Painful muscle spasms in the calf or foot during periods of inactivity 3. Paresthesias followed by numbness that may affect the lips, nose, and ears in addition to the limbs 4. POSITIVE Trousseau's and Chvostek's Signs 5. HYPERACTIVE DTR's 6. Anxiety and irritability Hypocalcemia Assessment: Renal - ansUrinary output varies depending on the cause. Hypocalcemia Assessment: GI - ansINCREASED gastric motility; hyperactive bowel sounds Cramping, Diarrhea Hypocalcemia Assessment: Labs - ansSerum calcium less than 8.6 mg/dL EKG Changes 1. Prolonged ST interval 2. Prolonged QT interval Hypercalcemia Assessment: CV - ans1. Increased HR in the early phase; BRADYcardia that can lead to cardiac arrest in late phase. 2. Increased BP 3. Bounding, full peripheral pulses Hypercalcemia Assessment: Respiratory - ansIneffective respiratory movement as a result of profound skeletal muscle weakness Hypercalcemia Assessment: Neuromuscular - ans1. Profound muscle weakness 2. Diminished or absent DTR's 3. Disorientation, lethargy, coma. Hypercalcemia Assessment: Renal - ansUrinary output varies depending on the cause Formation of renal calculi; FLANK PAIN Hypercalcemia Assessment: GI - ans1. Decreased motility and hypoactive bowel sounds 2. Anorexia, nausea, abdominal distention, constipation Hypercalcemia Assessment: LABS - ansSerum calcium greater than 10 mg/dL EKG changes: 1. Shortened ST segment 2. Widened T wave Some causes of hypocalcemia... - ans1. Kidney disease, polyuric phase 2. Diarrhea 3. Steatorrhea 4. Wound drainage, GI 5. Hyperproteinemia 6. ALKALOSIS 7. Acute pancreatitis 8. Hyperphosphatemia 9. Immobility 10. Removal or destruction of the parathyroid gland.